Disclaimer: Included quotes are intended to provide examples for readers. These are not quotes from individual persons and any resemblance to real persons, living or dead, is purely coincidental.
I received a message from the parent of a patient that read, “He finally did it.” Tragically, the boy was found dead in his college dorm room after hanging himself. I had treated the boy when he was 15 years old following a suicide attempt. At that time, the boy was suffering from depression and suicidal thoughts. These problems remitted with treatment, and there were no other suicide attempts during high school. He went to college, and saw a psychiatrist near the college for follow-up care.
Suicide prevention is perhaps our greatest challenge. Among youth ages 10 to 24 years, suicide is the second leading cause of death. Over 6000 individuals in the 10- to 24-year age group lost their lives to suicide in 2016.1 Although still a rare event statistically (nearly 15,000 individuals in the same age range died by unintentional injuries in 2016), many of us providing psychiatric care will lose patients to suicide.1 Despite the recognition that as much as we try it is not possible to prevent all suicides, there have been substantial advances in knowledge regarding treatment. This article reviews some of these advances, which have been selected to inform clinical care.
Adolescence offers a developmental window when early effective intervention may prevent potentially deadly patterns from becoming established. Although rare in childhood, rates of suicide deaths in the United States more than double from adolescence to young adulthood and, unlike other causes of mortality for adolescents (eg, motor vehicle accidents), suicide rates are increasing.1 The first onset of suicidal behavior often occurs during adolescence, and the rate of suicide attempts (SAs) and self harm more generally (including nonsuicidal self injury [NSSI], self harm with ambiguous intent, and SAs) also increases. For those of us who work with adolescents and/or their parents, the hope is that early recognition and intervention can prevent suicidal behavior and premature deaths.
Etiology, risk, and protective processes
Suicide has no single cause, and the causes and predictors of suicide and SAs vary across individuals. Due to this heterogeneity, most risk factors account for a small proportion of the variance in predicting suicide deaths. The variation in risk and protective factors across individuals has led to interest in machine learning and related approaches to identify individuals with heightened imminent risk for suicide, with the goal of intervening to prevent deaths. Application of machine-learning algorithms within health systems could potentially be used to identify high-risk individuals and provide monitoring and care to prevent suffering and deaths.2
A previous SA or self-harm history (hereafter referred to as SA/SH) is the most consistently replicated risk factor for suicide deaths and a strong predictor of premature death by unnatural causes (eg, drug overdose, car accidents, homicide).3 Prior SA/SH history, including NSSI particularly when associated with suicidal ideation (SI) and/or depression, is also a significant predictor of nonfatal SAs. Suicide deaths increase during the young adult years, are more common in males, and are often high among American Indians and Alaskan Native populations. SAs are more common in females. Depression, substance abuse, bipolar disorders, emerging psychosis, schizophrenia, sexual and gender minority status, bullying, exposure to suicide, and other forms of psychosocial stress are associated with increased risk for fatal and nonfatal SAs. Some medical treatments may also be associated with increased suicide risk (eg, steroids and steroid withdrawal). Sleep disturbance may be an indicator of imminent suicide risk. See reviews for more information on risk and protective factors.4
Dr Asarnow is Professor; Dr Fogelson is Clinical Professor; Ms Fitzpatrick is Clinical Research Coordinator; Psychiatry and Biobehavioral Sciences, University of California, Los Angeles; Dr Hughes is Assistant Professor, Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX. Dr Asarnow reports that she is a consultant/receives funding from the NIMH, the Substance Abuse and Mental Health Services Administration, the American Psychological Association, the American Foundation for Suicide Prevention, and the Klingenstein Third Generation Foundation. Drs Fogelson and Hughes and Ms Fitzpatrick report no conflicts of interest concerning the subject matter of this article.
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